Providing that a person is competent (that they understand what is going on and the consequences of their actions) and that they are acting voluntarily; the decisions of adults about physical intervention cannot be overridden or ignored (Arnorld.E, 1988). The Mental Capacity Act 2005 provides a statutory framework to empower and protect vulnerable people who are not able to make their own decisions. It makes it evident who can take decisions, in which situations, and how they should go about this. The Act is effective in England and Wales and came fully into force in April 2007. It also allows people to prepare for a time ahead for a when they may lose capacity. (NMC 2007).
Self neglect refers to situations in which there is no person responsible and neglect is the result of the older person refusing care. Self-neglect is often associated with mental health problems, including substance abuse, dementia, and depression. Older adults will often engage in such indirect life-threatening behaviours as severe lack of self-care, which could include refusal to eat, refusal to take medications, and failure to act in accordance with an understood medical course of therapy. These behaviours are often classified as non-compliance or passive suicide. Analysis of such occurrence reveals that these actions can be attempts by the patient to gain control of and to improve a negative life situation (thibault et al).
Self-neglect inevitably poses ethical dilemmas for nurses and healthcare staff involved in providing help. The balance between respect for the autonomy of the patient and the desire to act in a beneficent manner can often result in disagreement and tension. The issue of refusal of treatment and the determination of decisional capacity should be explored. Advocacy for the patient in the least invasive manner is recommended (Simmons et al).
Elderly people can abuse or neglect themselves by not caring about their own personal health and well-being. Elder self-neglect can lead to illness, injury or even death. Common needs that the elderly person might deny themselves or ignore are the following:
These potential problems highlight the need for co-ordinated multidisciplinary guidelines that set out the responsibilities of all professionals and the options for intervention. Having a clear focus on prevention and empowerment (Pettee, 1997; McCreadie, 2001). Interprofessional working involves complex interactions between two or more members of different professional disciplines, it is a collaborative venture (Mc Cray 2002) in which those involved divide the common purpose of developing mutually negotiated goals achieved through agreed plans and monitored and evaluated according to agreed procedures. This requires sharing of knowledge and expertise (Cook et al 2001) to facilitate joint decision making based upon shared professional viewpoints (Russell and Hymans 1999).
Good nutrition can be particularly difficult for the elderly patient, many factors can contribute including physiological changes, changes in nutritional needs, illness and physical limitations, food-medication interactions, depression and loneliness, and food insecurity are frequent causes of malnutrition in the elderly. It is usual for energy requirements to deplete with advancing age because people can become less active; however, it is important that older people continue to enjoy their food and remain active in order to ensure a healthy appetite, to prevent obesity and maintain mobility.
There area lot of possible reasons why people eat less as they get older. For example, some elderly people have difficulty chewing and swallowing, some may experience difficulties in shopping, preparing and cooking food. Others may cut back on what they buy due to financial constraints. ( British Nutrition Foundation 2004) It is to be expected that eventually all of us will grow older and begin to face more and more health problems as our age increases.
Elderly people are challenged by many illnesses and diseases that unfortunately, are incurable. Some illnesses and diseases that are more common in the elderly are Alzheimer's disease and dementia. Alzheimer's is a common cause and a form of dementia and can severely damage patient's cognitive functions and can ultimately end in death. Living with Alzheimer's disease or dementia can be distressing for both the sufferer and the family. Family and friends will find it very hard to deal with when a loved one begins slipping away and losing memory of who they are.
Where a person is suffering from Alzheimer's or dementia this should be documented and should outline part of their care plan. Communication with patients with dementia needs special attention and can be improved with calm and patience, the staff speaking to the patient simply but not speaking patronisingly to them, using touch and allowing time for the patient to try and comprehend what is being communicated to them. . Depression can be mistaken for dementia and left untreated, but depression is sometimes coupled with dementia. If an elderly person is suffering from depression, regardless of what else is happening, it should be treated. Even when coupled with dementia, if depression is treated, it could help with some of the confusion (Morris, p. 285 2004).
Self neglect is common and harmful. When elderly people are depressed, they may not take adequate care of themselves. Without counselling and medication for depression, this treatable condition left untreated will increase the risk of stroke and heart disease, and reduce a person's ability to recover from surgery, infection, and illness. Depression causes confusion and exacerbates dementia. It reduces a person's will to care for themselves, and lowers their energy levels (Morris, 2004, p. 282).
Communication with patients is now recognised as an essential part of nursing, it is not only important as a way of discovering or conveying information, but it is also acknowledged as the single and most important way of securing cooperation and compliance (Thompson et al, 1994, p.113). The nurse has a distinct advantage, over many other health care professionals in that they usually spend the most time with patients. In this role, they can interact on a clinical as well as social level with the patient and in almost every setting find things out about the patient that others providing care may not know. It is for this reason that nurses are the most logical persons to act as advocates for patients.
A form for such caring impulses can be seen in the role of the nurse as Advocate. This role has been described as one of the most challenging a nurse has to face. Advocacy has been described as "not a slogan or a hobby, and not to be entered into by the faint-hearted" (Copp 1984). The advocate role, though not only expected of the nurse within the multidisciplinary team, it can often be an inevitable result of the twenty four-hour responsibility of nurses for patient care (Cope.LA 1986) As an advocate for a patient a nurse might be able to influence care to better meet the holistic needs of patients. The nurse's role is one of advocate for the interests of the people in their care.
In an older person other symptoms may occur, including confusion, forgetfulness, and personality changes that may be mistakenly attributed to dementia. Neglect of personal hygiene and diet in an older person may also be an indication of underlying depression. Sometimes, depressive illness manifests itself as a physical symptom, such as tiredness or may cause associated physical problems such as constipation or headache. (BM caring for the NHS July 2006) Nurses are bound by their professional Code of Conduct. Their unchanging professional expectation is the clear duty of care, to safeguard the public and at all times to put their patients' interests and safety first (NMC 2002).
.The Patient's Charter (DoH, 1995) formalised the idea of respect for all patients as individuals and also the need to explain the risks and benefits before they decide to agree to treatment or not; the concept of 'best interests' is closely linked with the Human Rights Act (1998) which states that quality of life is a right to humane treatment. These concepts are embodied in the Code of Professional Conduct (NMC, 2004) and in English law and should be followed under all circumstances.
Frequently there are no right or wrong answers in ethical debate, but for the nurse, there is no shortage of useful guidance available to assist reflection on and justification for the decisions to be made or those that have been made. Nursing documentation should reflect on how decisions have been reached, how patients have been involved in treatment decisions and whether the prescribed treatment has been effective and acceptable to the patient. Even a person who might be judged as being capable of rational thought do make irrational decisions, and nurses might try to change their minds but, ultimately we have to respect their wishes (Rumbold 1999, p.237).
In conclusion the sharing of information and knowledge with older people within a nurse-client relationship are important components of choice, autonomy and interdependence, what if patients cannot make informed choices about their care and treatment, and what if their voices cannot be heard. The role of the nurse is crucial in supporting older people whilst allowing them to exercise their right to make choices about factors that will affect their lives.